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GRAND CASE PRESENTATION

Introduction Client’s Profile Pathophysiology NCP

Group 10
Station 4
7-3PM
Capitol University
Medical City
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

COPD, or chronic obstructive


pulmonary disease, is defined by the
National Heart Lung and Blood
Institute as a progressive disease
that makes it hard to breathe.
"Progressive" means the disease
gets worse over time.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

It can cause:
coughing that produces large amounts
of mucus (a slimy substance)
wheezing
shortness of breath
chest tightness
and other symptoms
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Cigarette smoking
is the leading
cause of COPD as
evidenced by the
smoking history or
exposure of the
COPD patients.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

A smoker can be:


•Active smoker - those who intentionally
smoke using cigarettes and cigars
•Passive smoker - those who breathe in
other people’s smoker hence called
involuntary or secondhand smoker.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Types of smoker
•Current smoker - has smoked 100 cigarettes in a lifetime
and now smokes every day or some days.
•Former smoker - he has smoked 100 cigarettes in a
lifetime and does not smoke at all.
•Never smoker - has not smoked a cigarette and has never
smoked 100 cigarettes in a lifetime.
•Light smoker - smokes 5 or fewer cigarettes per day
occasionally.
•Moderate smoker - smokes 6 to 21 cigarettes a day.
•Heavy smoker - smokes more than 21 cigarettes a day.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

There has been an Anti-Smoking


Law in the country that prohibits
everyone from smoking in public
places and further prohibits the
minors from totally smoking.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

•7 out of 10 Filipinos
smokes
• 5.5 million of them have
the disease
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

COPD
• 8th leading cause of death in the country
next to heart disease, vascular system
diseases, cancer, accidents, and some other
illnesses.
Philippines
• 2nd country in Asia who has the highest
number of COPD cases next to Indonesia.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

The main symptom of an exacerbation


• Increased breathlessness often accompanied by:
wheezing,
chest tightness,
increased cough and sputum, and  
Fever
•may   also   be accompanied   by non-specific complaints such as
malaise
insomnia
fatigue
depression
confusion.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

•The group has decided to go deeper with this


case for the following reasons:
•To enhance the group members’ knowledge
about the entire case;
•To make people aware of the current health
status in the Philippine setting most importantly
the respiratory cases;
•To inform people, both current and non-smokers,
on the ill-effects of smoking to our health and
how it gradually leads to death;
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

• To strengthen and help in the promotion of


the Anti-Smoking campaign mandated by
the lawmaking body of the Philippine
government;
• To encourage non-smokers and even
current smokers to quit smoking as early as
possible and relay to them the advantages
of quitting and not engaging into it at all.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Capitol University Medical City


7-3 pm shift
November 18, 2010 (Thursday)
•Initial assessment
November 19-20, 2010 (Friday)
•The group was able to render care to the patient
November 21, 2010 (Sunday)
•Reassessment of the patient
•Last day of assessment
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Patient’s Profile
Age: 71 years old
Sex: Male
Status: Married
Address: Balingasag, Misamis Oriental
Citizenship: Filipino
Religion: Roman Catholic
Occupation: Retired
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Date of Admission: November 18, 2010


Time of Admission: 12:25 am
Attending physician: Dr. Obsioma
Room: CUMC Station 4 - 436
c/c: Fever and cough
Admission Diagnosis: Recurrent Chronic Obstructive
Pulmonary Disease
Principal Diagnosis: Recurrent Chronic Obstructive
Pulmonary Disease
Final Diagnosis: Recurrent Chronic Obstructive
Pulmonary Disease Assessment
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

History of Present Illness


A few hours PTA, patient experienced
onset of high grade fever of 39.0 degrees
Celsius associated with non-productive
cough for a week. Patient already had
Fluimucil for cough. Onset of fever
prompted upon admission.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Patient’s special procedures include:


Year Operation performed
2002 Quadruple heart bypass surgery
2003 Right eye retinal hemorrhage surgery
2005 Left eye removal of cataract
2008 Right leg below the knee amputation
2009 TURP with bilateral orchiectomy
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

• Smoker for 18 years


• Alcoholic beverages drinker for 23 years
• Had maintenance medications of
insulin,
Humolin-R,
ipatropium and amlodipine
• No known food or drug allergies.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Family history
•Diabetes mellitus type 2
•Hypertension
•Asthma
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Before confinement During hospitalization


Nutrition/Metabolic Pattern
 No special diet  Diabetic diet
 Eats three times a day  Eats three times a day
 Good appetite  Good appetite
 Consumes 4 cups of dark  Does not drink coffee
coffee  No nausea and vomiting
 No nausea and vomiting
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Before confinement During hospitalization


Elimination Pattern
 Defecates once a day  Defecates every other day
 Urinates about 500-800cc  Urinates an average of
in 8 hours 1600cc in 8 hours
 Yellowish urine  Yellowish urine
 Urinates at the bathroom  Urinates at bedside
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Before confinement During hospitalization


Activity/Exercise Pattern
 Talks with friends and  Talks with friends and
family family
 Does household  Does active ROM
chores as everyday exercise on bed
exercise
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Before confinement During hospitalization


Sleep-Rest Pattern
 Average of 8 hours of  Average of 4 hours of
sleep sleep
 Does not take a nap  Takes a nap in the
 Difficulty sleeping due to morning and afternoon
coughing episodes  Difficulty sleeping due to
coughing episodes
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Self-Perception/ Self-Concept
Pattern
“Kung unsa man ang naa sa ako,
mag.enjoy ko…kung nay kwarta,
mag.enjoy ra gihapon. Kay mao
ramay kalipay” as verbalized.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Cognitive/ Perceptual Pattern


• Conscious
• Bit restless
• Oriented to time, place, person
• In calm emotional state
• Exhibited appropriate behavior and
response during conversation
• Verbalized no dizziness or tingling sensation
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Role/Relationship Pattern
• married
• retired
• has four children- all working
professionals and are in good physical
condition
• live with his family in Balingasag
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Coping/ Stress-Tolerance Pattern


“Oo, stressful gyud kung naa sa hospital,
ga.problema ka pirmi kung kanus-a na ka
pwede mouli. Pati kwarta, gaproblema ko,” as
verbalized.
As for relaxation, he usually reads books and
newspapers or watches television. His vital
support group is his family and significant
others.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Value/ Belief Pattern


 

• Roman Catholic
• Always goes to church and chats with his
church mates a lot
• God is vital to everyone and he trusts in God
on whichever turn his condition will be.
• He says that hospitalization truly interferes
as he can’t go to church because of his
illness.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Review of Systems
General oriented to time, place, and person; a bit
restless
Integumentary no rashes noted
EENT no epistaxis
Musculo-skeletal no joint pain
Respiratory no hemoptysis
Cardiovascular chest pain noted
Gastrointestinal no diarrhea
Genito-urinary no dysuria
Nervous no seizure
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Review of Systems
Skin no rashes
Head-EENT dusky pulpebral conjunctiva,no
lymphadenopathy
Lymph nodes no cervical lymphadenopathy
Lungs Symmetrical chest expansion, (+) crackles at
the left anterior and
right posterior lung base, (+) wheezing sound
noted
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Review of Systems
Cardiovascular enlarged shape, no murmur

Abdomen flat, soft, non-tender, no-


organomegaly
Musculo- no limitation of joint movement
skeletal
Extremities right below knee amputated, no
cyanosis
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP
 
NURSING SYSTEM REVIEW CHART

Impaired Vision due to


retinal hemorrhage surgery
in 2002

Crackles upon
Crackles upon auscultation
Post Operative Scar
auscultation
(heart bypass surgery) in
2005

Removed
prostate

Below Knee Below Knee


Amputation Amputation

Laboratory
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Chronic obstructive pulmonary disease (COPD),


also known as chronic obstructive lung disease
(COLD), chronic obstructive airway disease
(COAD), chronic airflow limitation (CAL) and
chronic obstructive respiratory disease (CORD),
refers to chronic bronchitis and Asthma, a pair of
commonly co-existing diseases of the lungs in
which the airways become narrowed. This leads
to a limitation of the flow of air to and from the
lungs causing shortness of breath.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

COPD is caused by noxious particles or gas, most


commonly from tobacco smoking, which triggers
an abnormal inflammatory response in the lung.
The inflammatory response in the larger airways
is known as chronic bronchitis, which is diagnosed
clinically when people regularly cough up sputum.
The natural course of COPD is characterized by
occasional sudden worsenings of symptoms called
acute exacerbations, most of which are caused by
infections or air pollution.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Chronic bronchitis is defined in clinical terms


as a cough with sputum production on most
days for 3 months of a year, for 2
consecutive years. In the airways of the lung,
the hallmark of chronic bronchitis is an
increased number (hyperplasia) and
increased size (hypertrophy) of the goblet
cells and mucous glands of the airway.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

As a result, there is more mucus than usual in the


airways, contributing to narrowing of the airways and
causing a cough with sputum. Microscopically there is
infiltration of the airway walls with inflammatory cells.
Inflammation is followed by scarring and remodeling that
thickens the walls and also results in narrowing of the
airways. As chronic bronchitis progresses, there is
squamous metaplasia (an abnormal change in the tissue
lining the inside of the airway) and fibrosis (further
thickening and scarring of the airway wall). The
consequence of these changes is a limitation of airflow.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Asthma on the other hand is a common chronic


inflammatory disease of the airways characterized
by variable and recurring symptoms, reversible
airflow obstruction, and bronchospasm.
Symptoms include wheezing, coughing, and
shortness of breath. Treatment of acute
symptoms is usually with an inhaled Ipratropium
+ Tiptropium. Symptoms can be prevented by
avoiding triggers, such as allergens and irritants,
and by inhaling corticosteroids.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

COMPLETE BLOOD COUNT


TEST Result Result Reference Value Unit
11/18/2010 11/20/2010
Hgb 10.2 10.3 11.7 – 14.5 g/L

Hct 30.0 31.0 34.1 – 44.3 gm%

WBC Count 14,906 16,100 5,000 – 10,000 Cell/mm3

Segmenters 86.0 76.0 45-70 %

Lymphocyte 10 15.0 18-45 %

Monocyte 0.4 5.0 4-8 %

Eosinophil 4.0 4.0 2-3 %

RBC 3.38 3.53 4.2 – 5.4 10*6/µL


Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Hemoglobin (Hgb)
This test measures the grams of
hemoglobin found in a deciliter of
whole blood. It correlates closely
with the RBC count and affects the
Hgb-RBC ratio.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Purpose: To measure hemoglobin if


there is any indication of organ ischemia
occurs and to monitor response to
therapy.
Lab Result :  Hgb
Indication/s: Low hemoglobin
concentration indicates impaired renal
function.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Hematocrit (Hct)
It measures the percentage by volume of
packed RBC in a whole blood.
Purpose: To assess the extent of a
patient’s blood loss.
Lab Result :  Hct
Indication/s: Low Hct suggests
hemodilution.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Red Blood Cells (RBC)


also known as erythrocyte
count, reports the number of
RBC’s found in a microliter of
whole blood.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Purpose: To supply figures for computing


the erythrocyte indices which reveal RBC size
and hemoglobin contents and to support
other hematologic tests.
Lab Result:  RBC
Indication/s: A depressed count may indicate
fluid overload, alcohol abuse, and impaired
renal function.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

White Blood Cells (WBC)


- part of the complete blood count, count
reports the number of WBC found in a
microliter of whole blood.
Purpose: To determine infection or
inflammation or to determine the need for
further test, such as WBC differential or bone
marrow biopsy.
 
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

 Lab Result:  WBC


Indication/s: An elevated WBC
count commonly signals infection
such as his infection in his
respiratory tract due to chronic
bronchitis.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Segmenters (Segs)
 

also known as Segs count,


reports the number of
segmenters found in a
microliter of whole blood
expressed in cell percentage.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Purpose: To determine infection or


inflammation or to determine the
need for further test
Lab Result:  Segs
Indication/s: An elevated segs count
commonly signals severe infection, due
to chronic bronchitis.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Lymphocyte
Lab Result:  Lymphocyte
Indication/s: Caused by
corticosteroid therapy
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

 Monocyte
Lab Result:  Monocyte
Indication/s: Caused by
corticosteroid therapy
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Eosinophil
Lab Result:  Eosinophil
Indication/s: May be
increased by allergic
reactions, and skin infection.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

CLINICAL CHEMISTRY

TEST Result Reference Unit


11/18/2010 Value

Creatinine 2.00 0.60 – 1.30 mg/dL

Potassium 3.27 3.5 – 5.3 mmol/L


Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Creatinine
is a nonprotein end product of
creatinine metabolism. Serum creatinine
test provides a more sensitive measure
of renal damage than blood urea
nitrogen levels because renal
impairment is virtually the only cause for
creatinine elevation.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Purpose: To assess renal glomerular


filtration and to screen for renal
damage.
Lab Result:  Creatinine
Indication/s: Elevated serum creatinine
levels generally indicates renal disease
that has seriously damaged 50% or more
of the nephrons.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Potassium (K+)
is the major intracellular cation. It is
important in maintaining cellular
electrical neutrality. Evaluation of
serum potassium measures the
extracellular levels of this
electrolyte.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Purpose: To evaluate clinical signs of


potassium excess or depletion; to
monitor renal function, acid-base
balance and glucose metabolism; to
detect the origin of arrythmias; to
evaluate neuromuscular and endocrine
disorders.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Lab result:  Potassium


Indication/s: Occurs with depletion
of total body potassium caused by
shifts from extracellular fluid to
intracellular fluid. Renal disorders
also cause hypokalemia.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Nursing Implication/s:
Observe patient for decreased
reflexes, mental confusion,
hypotension, muscle
weakness.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

URINALYSIS (11/18/10)
Test Result
Color Yellow
Transp Turbid
Reaction 6.0
Sp gravity 1.015
Sugar Negative
Protein +3
Coarse granular cast 1-2 cells/ hpf
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Pus cells 1-5 cells/ hpf


Rbc 0-2 cells/hpf
Epithelial cells Few
Squamous epithelial Few
Bacteria Abundant
Yeast yellow Rare
Amorphous urates Few
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Protein
The urinalysis is a routine
screening test which is usually done
as a part of a physical examination,
during preoperative testing and
upon hospital admission.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

It is used in the diagnosis of


infectious of the kidney and
urinary tract and also in the
diagnosis of diseases
unrelated to the urinary
system.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

In general, if the urine sample is left


standing too long bacteria begin to
split urea into ammonia, resulting in
alkaline urine, should this occur, test
results regarding protein and the
microscopic examination of casts will
be inaccurate.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

A delay in testing may also


result in falsely low glucose,
ketone, bilirubin abd
urobilinogen values and
falsely elevated bacteria
levels.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Indication: the result shows


that there is increase in
protein it indicates DM,
Emotional stress, malignant
hypertension and orthostatic
proteinuria.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Coarse Granular Cast


The cellular material in
epithelial cells and WBC break
down, the resulting granular
particles form granular casts.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Lab Result:  granular cast


Indication: the result show
that there is increase in
granular cast indicates acute
and chronic renal failure and
malignant hypertension.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Red Blood Cells


Red blood cells, aggregates of cells
formed in the renal tubules, may also
be found in the urine their presence
usually indicates the blood is of
glomerular origin, something which
may occur in patients with variety of
conditions.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Lab Result:  in RBC


Indication: the result show
that there is an increase in
RBC, indicates benign
prostatic hypertrophy and
urinary tract infection.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Bacteria
Bacteria may also be noted via the
microscopic examination of the urine. Should
bacteria be found during a routine urinalysis,
culture and sensitivity testing of the urine
should be done to determine the organism
and to provide assistance in determining
appropriate antimicrobial therapy.
Chronic obstructive
pulmonary disease
Introduction Client’s Profile Pathophysiology NCP

Lab Result:  presence of


bacteria
Indication: the result shows
that there is presence of
bacteria in urine indicating
urinary tract infection.
ASSESSMENT DATA NURSING GOALS AND OBJECTIVES
(Subjective & Objectives DIAGNOSIS NURSING INTERVENTIONS AND RATIONALE EVALUATION
Cues) (Problem and
etiology)

Subjective Cues: At the end of 5-10 Independent: Goals met. After 10


“Galisod ko ug ginhawa” Impaired minutes of nursing 1) Re-Monitored level of consciousness. Note for any minutes of nursing
as verbalized by the
patient.
gas intervention, the patient
will be:
changes.
R: Restlessness and anxiety are common manifestations
intervention, the
patient was able to:
Objective Cues: exchange  Able to improve of hypoxia. Worsen ABG’s accompanied by confusion are  Show signs of
 Crackles heard ventilation by indicative of cerebral dysfunction due to hypoxemia. improved
upon auscultation R/T altered increasing the 2) Re-Assessed respiratory rate, depth. Note use of ventilation and
 02 Sat – 93% oxygen oxygen saturation accessory muscle and pursed lip breathing. adequate
 RR: 32 cpm to 95% and above. R: Useful in evaluating the degree of respiratory distress. oxygenation of


Restlessness
Orthopnea
supply  Decrease signs of
restlessness
3) Re-Monitored cardiac status and rhythm.
R: Tachycardia, dysrhythmias and change in blood
tissues as
evidenced by
 Shortness of  Show decreased pressure can reflect systemic hypoxemia on cardiac increased
breath noted respiratory rate function. oxygen
 Ineffective from 32 cpm to 27 4) Positioned patient to semi-Fowlers or position of saturation of
coughing cpm. comfort. 96%.
 Dyspnea R: To promote maximum lung expansion.  He also showed
 Capillary refill - 4 5) Performed chest tapping after nebulization. signs of
seconds R: To get rid of mucus secretions imparing the efficacy of decreased
the respiratory pattern. restlessness.
6) Instructed to perform deep breathing exercises such  However, his
as pursed lip breathing. respiratory rate
R: To promote maximum lung expansion. was decreased
Dependent: to 27 cpm only.
7) Administered oxygen therapy via nasal canula of 2
LPM.
R: To correct hypoxemia
8) Administered hydrocortisone 100 mg, IVTT q 4 hours
as prescribed.
9) Administered Combivent 1 nebule, OD as prescribed
by physician.
R: To aid in normalization of respiratory pattern
10) Administered Senetide 250 mg discuss inhaler BID as
prescribed by physician
R: To aid in normalization of respiratory pattern
ASSESSMENT DATA Nursing Diagnosis GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION
(Subjective and Objective (Problem and Etiology)
Cues)
Subjective: After 5-10 minutes of INDEPENDENT: Goals partially met.
“ Dili kayo ko kaginhawa Ineffective nursing patient will be 1. Re-monitored respirations and breath After 10 minutes of
tungod sa akong ubo nga
dili kayo gakaluwa" as
airway able to: sounds, noting rate and sounds
R: indicative of respiratory distress and
nursing care patient
was able to:
 Improve airway
verbalized clearance patency. accumulation of secretions.  Improved airway
Objectives: 2. Positioned the patient into semi-fowlers or patency as
 Crackles heard upon related to  Expectorate mucus
secretion
position of comfort. evidenced by


auscultation
Productive cough:
retained  Decrease 3.
R: To provide maximum lung expansion.
Increased fluid intake into 2-3L per day
expectoration of
mucus secretion.
yellowish color mucus respiratory rate unless contraindicated.  However, rales
 Dyspnea from 32 to 27 cpm R: Hydration helps decrease viscosity off were still noted
 Use of trapezius secretion  Show 02 saturation secretions facilitating expectoration. upon
muscle when increased from 93% 4. Encouraged pursed- lip breathing auscultation.
breathing to 95% exercises.  Respiratory rate
 Nasal flaring R: Provide client with some means to was only
 Restlessness cope dyspnea and reduced air trapping. decreased to 27
 RR- 32cpm 5. Performed chest tapping after cpm.
 O2- 93% administration of nebulization.  02 Saturation
 Orthopnea R: To aid in expectoration of phlegm. was increased to
DEPENDENT: 96%.
1) Administer oxygen therapy via nasal
canula of 2 LPM.
R: To correct hypoxemia
2) Administer Combivent 1 nebule every 8
hours as ordered.
R: Helps to dilate and smoothen bronchioles.
3) Administer Fluimucil 600mg 1tab in 1/3
glass of water O.D as ordered.
R: To liquefy secretions.
4) Administered Senetide 250mg discuss
inhaler BID 8am, 6pm.
R: Helps dilate and smoothen bronchial area.
ASSESSMENT DATA NURSING GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION
(Subjective & Objectives DIAGNOSIS
Cues) (Problem and
etiology)

Subjective Cues: At the end of 15-30 Independent: Goals partially met.


“Paspas kayo akong ginhawa” Ineffective minutes of nursing 1) Re-Auscultated chest periodically, notify After 30 minutes of
as verbalized by the patient.
Objective Cues:
breathing intervention, the patient
will be able to:
absence and equality of breath sounds.
R: To evaluate presence/character of breath
nursing intervention,
the patient:
 Crackles heard upon pattern R/T  Improve ineffective sounds/secretion.  Has shown
auscultation respiratory pattern 2) Re-Assessed respiratory rate, depth. Note improved
 02 Sat – 92% respiratory by normalization of use of accessory muscle and pursed lip effective
 Tachypnea; RR: 32 cpm muscle the respiratory rate breathing. respiratory
 Dyspnea from 32 cpm to 27 R: Useful in evaluating the degree of pattern as


Restless
Nasal Flaring
weakness cpm.
Long term goal: 3)
respiratory distress.
Encouraged slower and deep respirations,
evidenced by a
slower rate in
 Shortness of breath  Show and maintain use of pursed-lip technique. breathing of 27
 Use of trapezius progressive R: To provide client with some means to cope cpm from 32
muscle to breathe normalization of dyspnea and reduce air trapping. cpm.
 Orthopnea breathing pattern 4) Positioned patient to semi-Fowlers or Long term goal:
within the range of position of comfort.  However, the
12-24 cpm. R: To promote maximum lung expansion. group has not
5) Performed chest tapping after nebulization. evaluated the
R: To get rid of mucus secretions imparing the long term goal
efficacy of the respiratory pattern. for the patient
6) Provided rest periods between as we had only
scheduled activities and treatments. taken care of
R: To limit fatigue the patient for 2
Dependent: days.
7) Administered oxygen therapy via nasal
canula of 2 LPM.
R: To correct hypoxemia
8) Administered Combivent 1 nebule, OD as
prescribed by physician.
R: To aid in normalization of respiratory pattern
9) Administered Senetide 250 mg discuss
inhaler BID as prescribed by physician
R: To aid in normalization of respiratory pattern
ASSESSMENT DATA NURSING GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION
(Subjective & Objectives DIAGNOSIS (Problem
Cues) and etiology)

Subjective Cues:
“Diri ra ko gapangihi sa
Activity At the end of 1-2 days of
nursing intervention, the
Independent:
1) Re-evaluated client’s response to activity.
Goals partially met.
 Patient
bedside kay dali ra kayo ko intolerance patient will be able to: Note reports of dyspnea, increased showed and
kapuyon kung mu.adto pa ko related to  Demonstrate weakness/fatigue, and changes in vital signs demonstrated
ug CR” as verbalized by the improved activity during and after activities. an improved
patient. exhaustion tolerance without R: Establishes client’s capabilities/needs and activity
Objective Cues: dyspnea and fatigue facilitates choice of interventions. tolerance such
 Tachypnea upon associated Long term goal: 2) Assisted in passive range of motion exercises. as ambulation
exertion with  Participate in R: Promotes blood circulation. around the
 RR: 32 cpm
imbalance activities of daily 3) Provided a quiet environment and limit room and
 Dyspnea living more visitors during acute phase as indicated. sitting upright
 Easy fatigability between importantly in toilet Encourage use of stress management and but dyspnea
 O2 Saturation: 93% transfer and diversional activities as appropriate. was still noted
oxygen ambulation. R: Reduce stress and excess stimulation, upon exertion.
supply and promoting rest. Long term goal:
4) Assisted client to assume comfortable  However, we
demand position for rest/sleep. were not able
R: Client may be comfortable with head of bed to evaluate
elevated, sleeping in chair, or leaning forward on whether the
overbed table with pillow support. goal of
5) Provided a quiet environment and limit participating
visitors during acute phase as indicated. in activities of
R: Reduces stress and excess stimulation, daily living
promoting rest. were met.
Dependent:
6) Administered oxygen therapy via nasal
canula of 2 LPM.
R: To correct hypoxemia
7) Administered Combivent 1 nebule, OD as
prescribed by physician.
R: To aid in normalization of respiratory pattern
8) Administered Senetide 250 mg discuss
inhaler BID as prescribed by physician
R: To aid in normalization of respiratory pattern
ASSESSMENT DATA (Subjective NURSING GOALS AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
& Objectives Cues) DIAGNOSIS RATIONALE
(Problem and
etiology)
Subjective Cues: After 3-4 hours of nursing Independent: Goals partially met.
“Sa isa ka adlaw, daghan kayo Imbalanced intervention, patient will be 1) Weighted daily as indicated.  Patient was able to show
kog gakakaon pero ganiwang
gihapon” as verbalized by the
nutrition: able to:
 Ingest appropriate
R: Assess adequacy of nutritional
intake.
appropriate amounts of ingested
calories as indicated in his
patient.
Objective Cues:
less than 
amounts of calories
Display
2) Ascertained client’s dietary
program and usual pattern; 
diabetic diet.
He has also shown signs of
 Type 2 Diabetes Mellitus body usual/increased compare with recent intake. maintained usual energy level as
 Polyuria - 1600 mL/8 energy level R: Identifies deficits and evidenced by resumed ADLs
hours requiremen  Display normalization deviations from therapeutic such as walking around the
 Polydipsia - more than of blood glucose needs. room for exercise, clothing, and
2.5 liters per day ts related levels from 236 3) Adviced to eat foods low in eating.


Polyphagia
Poor muscle strength - to insulin mg/dL to 120 mg/dL
or lower.
sugar and
carbohydrates.
low in  He has also verbalized
adherence to the treatment


3/5
HGT - 236 mg/dL; Taken
deficiency  Verbalize adherence
to medication
R: To lessen increased blood
glucose level.
regimen by stating that he needs
to constantly monitor his
on November 19, 2010 regimen. 4) Encouraged compliance to glucose level and take his
 Weight: 67 kgs. (upon Long term goal: treatment regimen. medications as prescribed.
admission)  Maintain normal R: For faster recovery and prevent  However, his blood glucose level
 Weight: 65 kgs glucose levels from further complications. has only decreased to 186
(November 20, 2010) 80-120 mg/dL. Dependent: mg/dL after 4 hours of care.
 Weight loss = 2 kgs. 5) Performed fingerstick glucose Long term goal:
testing.  However, the group has not
R: To monitor blood glucose levels evaluated the long term goal for
and check for hyperglycemia or the patient as we had only taken
hypoglycemia. care of the patient for 2 days.
6) Administered Humulin R, 10
units, subcutaneous, STAT as
prescribed.
R: To correct high glucose level.
7) Administered Galvus 50 mg, 1
tab, OD as prescribed.
R: To correct high glucose level.
8) Administed Januvia 25 mg, 1
tab, OD as prescribed.
R: To correct high glucose level.

Drugs
Chronic obstructive
pulmonary disease

Thank

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